FACTOID

Qualitative Approach and Methods

Aim of the qualitative component

To optimise the acceptability, feasibility, and relevance of Acceptance and Commitment Therapy (ACT) for older adults with treatment-resistant GAD by grounding intervention design in the perspectives and experiences of those living with long-standing anxiety and those delivering care.

Qualitative methodology

A systematic, person-based approach to intervention planning and design in which qualitative methods were used alongside patient and public involvement.

Which qualitative methods were used?

• Individual interviews with older adults with TR-GAD and healthcare professionals across primary and secondary care.
• Focus groups with academic clinicians.
• Think-aloud interviews with service users during piloting of intervention materials.
• Ongoing Patient and Public Involvement via a Service User Advisory Group (SUAG).

Sampling & recruitment

Older adults aged 65+ with a primary diagnosis of GAD and evidence of non-response to prior psychological or pharmacological treatment were purposively recruited to reflect variation in age, illness duration, comorbidity, and care setting. Healthcare professionals included GPs, psychologists, psychiatrists, nurses, and occupational therapists. Service user advisors had lived experience of anxiety and/or mental health service use in later life.

Data analysis: how the team made sense of the data

Data were analysed using a structured framework approach that focused on beliefs about anxiety and ageing, coping strategies, experiences of prior therapies, expectations of change, and practical barriers to engagement. Findings were synthesised into guiding principles and design objectives, which were iteratively translated into intervention components and tested through think-aloud methods.

Findings, Learning & Impact

Summary of main findings

Qualitative analysis revealed that many older adults with TR-GAD viewed worry as a core part of identity (“I’ve always been a worrier”), had developed deeply entrenched coping strategies centred on avoidance and control, and were sceptical of therapies that promised symptom elimination. Participants valued being recognised as experts in their own condition and emphasised the importance of collaborative, respectful therapeutic relationships. These insights led to an adapted ACT intervention that foregrounded values, explicitly addressed beliefs about ageing and change, and provided practical supports to enable engagement despite cognitive or physical limitations.

Why were qualitative methods used in this project, and what did they enable?

Qualitative methods were essential to “open the black box” of intervention development for a population often excluded from psychological therapy research. They enabled the research team to:

• Identify why standard therapies were experienced as ineffective or alienating.
• Adapt ACT theory to the realities of ageing, multimorbidity, and long illness trajectories, grounding it in the lives of those who will use it.
• Test intervention materials in situ with older adults using think-aloud techniques
• Define acceptability and feasibility criteria prior to trial progression.

Lessons learnt / reflections?

• Treatment resistance in later life is often relational, biographical, and contextual rather than simply symptomatic.
• Interventions for older adults must explicitly address beliefs about ageing, identity, and the limits of change.
• Person-based qualitative development strengthens transparency, ethical robustness, and implementation relevance.

Impact & influence

The qualitative development work directly informed the manualised ACT intervention tested in the FACTOID feasibility study, which demonstrated good recruitment, retention, and session engagement, supporting progression to a future definitive trial. The project has had sustained methodological impact by advancing person-based qualitative approaches to intervention development in mental health research.

Links, Outputs & Resources

Links to publications

• Lawrence, V., Kimona, K., Howard, R. J., Serfaty, M. A., Wetherell, J. L., Livingston, G., Wilkinson, P., Walters, K., Jones, R., Wuthrich, V. M., & Gould, R. L. (2019). Optimising the acceptability and feasibility of acceptance and commitment therapy for treatment-resistant generalised anxiety disorder in older adults. Age and Ageing, 48(5), 741–750. Available here.
• Gould, R. L., Wetherell, J. L., Kimona, K., Serfaty, M. A., Jones, R., Graham, C. D., Lawrence, V., Livingston, G., Wilkinson, P., Walters, K., Le Novere, M., Leroi, I., Barber, R., Lee, E., Cook, J., Wuthrich, V. M., & Howard, R. J. (2021). Acceptance and commitment therapy for late-life treatment-resistant generalised anxiety disorder: A feasibility study. Age and Ageing, 50(5), 1751–1761. Available here.

Links to reports or briefs

• NIHR HTA study documentation and feasibility report